Healthcare Provider Details

I. General information

NPI: 1841216702
Provider Name (Legal Business Name): MIGGIE L GREENBERG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S GRAND
ST LOUIS MO
63104
US

IV. Provider business mailing address

3691 RUTGER AVE PROVIDER ENROLLMENT
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8720
  • Fax: 314-268-5494
Mailing address:
  • Phone: 314-977-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2001010861
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: